Basic Information
| Provider Information | |||||||||
| NPI: | 1962405522 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BYRD | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 5896 S RIDGELINE DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844056779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018660170 | ||||||||
| FaxNumber: | 8018660169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 7973035-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 031828 | 01 | AZ | MEDICARE | OTHER | 61788 | 01 | AZ | MEDICARE | OTHER |